Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management

Abstract

T reaTmenT management strategies for pituitary macroadenomas depend on numerous factors that guide the determination of medical management, surgical approach, and/or adjuvant therapeutic options. Maximal resection and adequate decompression of the neurological structures is the paradigm of care for symptomatic pituitary macroadenomas, with the exception of medically responsive prolactinomas.Since its inception by Schloffer in 1907 and then refinement and popularization by Hirsch, Guiot, and Hardy, the transsphenoidal approach has become the preferred route to the sella because of its relative safety profile. 9,14,16,17 The transcranial route still plays an important role in providing access to the sella in 1% to 4% of pituitary macroadenomas where direct visualization and accessibility via the transsphenoidal approach are limited. 38A transcranial approach should be considered in the surgical management of pituitary adenomas that display constriction at the diaphragma sellae, parasellar extension or inaccessible suprasellar extension off the midline, tumors of fibrous consistency with large suprasellar extension, and in patients with an active sinus infection or a coexisting adjacent aneurysm. Other cases that should be approached transcranially include those patients with ectatic intrasellar carotid arteries, 40 retrosellar extension, brain invasion with edema, involvement or vasospasm of the arteries of the circle of Willis, or encasement of the optic apparatus or invasion of the optic foramina. obJective Oculomotor cistern extension of pituitary adenomas is an overlooked feature within the literature. In this study, 7 cases of pituitary macroadenoma with oculomotor cistern extension and tracking are highlighted, and the implications of surgical and medical management are discussed. methods The records of patients diagnosed with pituitary macroadenomas who underwent resection and in whom preoperative pituitary protocol MRI scans were available for review were retrospectively reviewed. The patient and tumor characteristics were reviewed along with the operative outcomes and complications. results Seven patients (4.1%) with oculomotor cistern extension and tracking were identified in a cohort of 170 patients with pituitary macroadenoma. The most common presenting symptoms were visual deficit (6 patients; 86%), apoplexy (3 patients; 43%), and oculomotor nerve palsy (3 patients; 43%). Lone oculomotor nerve palsy was seen in 2 patients without apoplexy and 1 patient with an apoplectic event. Gross-total resection was achieved via a microscopic endonasal transsphenoidal approach with or without endoscopic aid to the sella in 14%, near-total resection in 29%, and subtotal resection in 57% of patients in the data set. coNclusioNs Pituitary adenoma extension along the oculomotor cistern is uncommon; however, preoperatively recognizing such extension should play an important role in the surgeon's operative considerations and postoperative clinical management because this extension can limit gross-total resection using t...

Endoscopic endonasal surgery for pituitary adenomas extending to the oculomotor cistern

“…The postoperative complete recovery of the affected oculomotor nerve by pituitary tumor is reported to occur in 68% to 100% . However, both cases in the present series exhibited only partial recovery.…”

“…The postoperative complete recovery of the affected oculomotor nerve by pituitary tumor is reported to occur in 68% to 100%. 14,[16][17][18] However, both cases in the present series exhibited only partial recovery. Compared with the previous reports, of which the major proportion consisted of apoplectic patients with the sudden onset of symptoms, both cases of the present series was nonapoplectic and required considerable time until the treatment decision was made by the patient due to the slow progressive nature of the symptoms.…”

“…In their series consisting of 7 cases of pituitary adenomas with extension to the oculomotor cistern, Hoang et al reported gross and near‐total removal in 1 and 2 cases, respectively . They concluded that the tumor compartment at the oculomotor cistern is the factor hindering the total resection of the tumor.…”

Endoscopic endonasal transoculomotor triangle approach for adenomas invading the parapeduncular space: surgical anatomy, technical nuances, and case series

“…In their initial experience, complete transsphenoidal resection of the extension of tumor in relationship to the superior wall of the cavernous sinus was not possible in any case, and a transcranial route was used for reexploration whenever the intracranial extensions were large. 6 Recently, Hoang et al 8 reported their experience with a particular subset of pituitary macroadenomas with extension along the oculomotor cistern, and highlighted the implications of this invasion pattern regarding resectability because this extension can limit gross-total resection (GTR) using the transsphenoidal approach alone, and consequently, adjuvant therapy or a transcranial approach might be indicated.ABBREVIATIONS AChA = anterior choroidal artery; ACP = anterior clinoid process; CSI = cavernous sinus invasion; GTR = gross-total resection; ICA = internal carotid artery; PCA = posterior cerebral artery; PComA = posterior communicating artery; PCP = posterior clinoid process; SCA = superior cerebellar artery.OBJECTIVE Pituitary adenomas may extend into the parapeduncular space by invading through the roof of the cavernous sinus. Currently, a transcranial approach is the preferred choice, with or without the combination of an endonasal approach.…”

“…In their initial experience, complete transsphenoidal resection of the extension of tumor in relationship to the superior wall of the cavernous sinus was not possible in any case, and a transcranial route was used for reexploration whenever the intracranial extensions were large. 6 Recently, Hoang et al 8 reported their experience with a particular subset of pituitary macroadenomas with extension along the oculomotor cistern, and highlighted the implications of this invasion pattern regarding resectability because this extension can limit gross-total resection (GTR) using the transsphenoidal approach alone, and consequently, adjuvant therapy or a transcranial approach might be indicated.…”